MANAGEMENT OF AGRESSIVE OR DISTURBED PATIENT IN EMERGENCY DEPARTMENT

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Presentation transcript:

MANAGEMENT OF AGRESSIVE OR DISTURBED PATIENT IN EMERGENCY DEPARTMENT Dr Roberta Branisteanu Emergency Medicine Consultant MD, PhD, MPhil November 2018

Objectives Recognize the agitated and potentially dangerous patient Describe the initial evaluation of an agitated patient Identify intervention options for the agitated patient

PS, 32ys – 28.08.18, hs 16.05 Pt BIB Police/Ambulance in ED Found wandering in Stansted Airport, confused, disorientated, agitated with ID cards and flight ticket Imp - ? Drugs use / ? Body packer Assessment – RR 18, HR 97, Sats 96%, BP 123/74, tº 36ºC, GCS 14/15, PERLA 5 mm Pt refused to have blood tests

Introduction Violence and aggression = range of behaviours or actions that can result in harm, hurt or injury to another person, regardless of whether the violence or aggression is physically or verbally expressed, physical harm is sustained or the intention is clear Acute Behavioural Disturbance (ABD)/ excited delirium = sudden onset of aggressive and violent behaviour and autonomic dysfunction, typically in the setting of acute on chronic drug abuse or serious mental illness ABD, or as it is also known ‘Excited Delirium,’ is the presentation of features of “acute delirium” and hyper-adrenergic autonomic dysfunction and must be considered a medical emergency.

Introduction England - 68,683 assaults reported against NHS staff between 2013 and 2014: 69% in mental health or LD settings 27% against ambulance staff 25% involving primary care staff 26% involving acute hospital staff ED is the most common setting in the hospital for employee assault! USA - 1/3 of teaching hospital EDs report daily verbal threats and 1/4 restrain at least one patient per day

Stratification of aggressive behaviour Calm and nonthreatening: Frustration only without overt signs of agitation. Verbal agitation, wherein speech patterns indicate irrational Verbal hostility, wherein more aggression is conveyed Verbally threatening, wherein actual threats are conveyed Physically threatening: Patient assumes a fighters stance and makes a fist. Physically violent: Patient physically attacks

“Early Warning Signs" of Violence Pt exhibits or threatens violence. Pt makes ED staff anxious or fearful. Behavior alternates between shouting / dozing, cooperation / belligerence. Pt expresses fear of losing control. Pt is uncooperative, hostile, agitated and unable to sit still.

“Early Warning Signs" of Violence 6. Pt is intoxicated with alcohol or medications or withdrawing from drugs. 7. Pt has a past history of violence. 8. Pt has tense, rigid posture, is easily startled and suspicious. 9. Pt has suggestive tattoos (?relationship to a violent organization or gang).

Initial Actions and Primary Survey ABCDE aproach AcBC aproach if suspected head or neck trauma Measure of all vital signs (HR, RR, SatO2, BP, tº, GSC) Blood glucose Promoting Safety

Methods of Avoiding Violence Avoid eye contact with patient. Do not block exits and leave door to room open. Maintain distance from potentially violent patient. Adopt passive, non-confrontational posture and attitude. Treat patient as you expect him to behave. Offer food or drink.

Methods of Avoiding Violence 7. Do not make challenging or provocative remarks. 8. If patient acts out, tell patient directly "your behavior is frightening others and we cannot allow such behavior". 9. Do not turn your back on potentially violent patient. 10. Never underestimate the potential for violence.

Evaluation and Diagnostic Testing Priorities in the management of the agitated patient to identify and treat life-threatening diagnoses manifesting as agitated behaviour to assess and secure respiratory and hemodynamic stability to obtain a more complete history and physical exam

Evaluation and Diagnostic Testing assessment of mental status neurologic exam (including meningeal signs) marks of trauma (head and neck exam) evidence of a toxidrome evidence of intoxication assessment for infectious causes of agitation (nuchal rigidity, skin exam, pulmonary exam, abdominal exam).

Evaluation and Diagnostic Testing Routine laboratory testing is generally of low yield in the evaluation of agitated patients. Diagnostic testing - guided by hx, physical exam and vital signs. Head CT - considered for agitated patient with evidence of head trauma. Blood gas - indicated where excited delirium is suspected, after safe control of the patient’s behavior.

Pyschiatric Vs Organic Etiology Suggests Psychiatric Etiology Suggests Organic Etiology Oriented Disoriented Alert Depressed level of consciousness Gradual onset Sudden onset Psychiatric history No psychiatric history Normal vital signs Abnormal vital signs Normal physical exam Abnormal physical exam Age < 40 years Age > 40 years (without psychiatric hx) Auditory hallucinations Visual hallucinations Flattened affect Emotional lability Able to redirect Unable to sustain attention

Pyschiatric Vs Organic Etiology Psychiatric Etiology Hyperthyroidism Depression Hypoglycemia Conduct disorder Traumatic Brain Injury Attention Deficit Hyperactivity Disorder Delirium Bipolar Disorder Mnemonic formula FIND ME! Impulse Control Disorder Functional Psychosis Infectious Impulsive behavior Neurologic Substance intoxication Drugs Substance withdrawal Metabolic Post-traumatic stress disorder Endocrine

Treatment The goals of intervention on an agitated patient in the ED: to calm the patient in order to resume a more normal patient-physician relationship to obtain informed consent to enable patient and staff safety

Principle The sooner agitation and escalating violence is addressed, the safer it will be for both the patient and ED staff!

Techniques to use for violent and agitated patient Verbal de-escalation Physical restraint Chemical restraint Seclusion

Verbal De-escalation speak to the agitated patient in a calm, empathetic, yet controlled voice use a non-confrontational approach be mindful of your body language avoid potentially threatening stances (crossing your arms, waving a finger) give assurance that they will not be harmed clear consequences for continued disruptive and dangerous behaviors Health and social care provider organisations should give staff training in de-escalation that enables them to:… Breakaway techniques

Physical Restraint Indications for emergency sedation and restraint include the prevention of imminent harm to - the patient - to others - to the immediate environment In the UK, human rights are protected by the Human Rights Act of 1998. Any physical intervention must be reasonable, proportionate and necessary, as determined by the person at the time, in order to be lawful.

Physical Restraint any device that restricts freedom of movement of patient's body soft restraints placed on the wrists and ankles vest restraints placed over the torso team of at least 5 people required monitoring of the patient and documentation required Manual restrain or any other device that restricts freedom of movement

Physical Restraint

Physical Restraint

Chemical Restraint – Rapid Tranquilisation use of medications to confine bodily movement therapeutic objective of reduction in agitation or aggression with minimal sedation to allow for timely assessment and treatment of any medical condition that requires acute intervention

Route of Administra tion Chemical Restraint Class Drug Dose Route of Administra tion Onset of Action Side Effects Benzodiazepine Lorazepam 2-4 mg IV/IM/PO 5-30 min Respiratory depression, excessive sedation Midazolam 5 mg 10-30 min Typical Antipsychotic Haloperidol 2.5-10 mg PO/IM/IV 30-60 min Extrapyramidal symptoms, Neuroleptic Malignant Syndrome

Route of Administr ation Chemical Restraint Class Drug Dose Route of Administr ation Onset of Action Side Effects Atypical Antipsychotic Ziprasidone 10 mg q 2 hrs or 20 mg q 4 hrs PO/IM 15-20 min QTc prolongation Risperidone 2 mg q 2 hrs PO < 90 min orthostatic hypotension Olanzapine 5-10 mg q 2-4 hrs 15-45 min IM 3-6 hrs PO Orthostatic hypotension

Chemical Restraint Ketamine has many properties that make it a useful sedative agent in the management of ABD (RCEM recommandation). - very rapid onset of action when administered IV or IM - protects airway reflexes and increasing doses lead to more prolonged duration of sedation whilst rarely affecting respiratory drive - inhibit the reuptake of catecholamines causing sympathomimetic side effects (increase in HR, BP, cardiac output and myocardial oxygen consumption) - emergence phenomenon?, managed by the administration of benzodiazepines

Rapid Tranquilisation Use of a neuroleptic agent such as haloperidol alone or in combination with a low-dose benzodiazepine (lorazepam or midazolam) For most patients - 2 mg lorazepam po is recommended For very challenging situations (when urgent control is required) - IM haloperidol (5-10 mg) and/or IM lorazepam 2 mg can be administered Intravenous drugs should be used only in exceptional circumstances For very challenging situations (in which urgent control is required) IM haloperidol (5-10 mg) and/or IM lorazepam 2 mg can be administered. This is a potent cocktail which is commonly used. Traditional neuroleptics such as haloperidol have well recognised side effects such as prolongation of the QTc interval and cardiac arrhythmias. NICE does recommend the use of haloperidol with promethazine for rapid tranquilisation in the management of violence and aggression but only if the patient has taken antipsychotic medication previously or they have previously had an ECG1. However, this background information for an individual with ABD is unlikely to be available at the time of their initial presentation. Appropriate patient monitoring is required. IM drugs may take up to 30 minutes to begin to have an appreciable effect.

Rapid Tranquilisation Whichever sedative agent is chosen, it must be one that the treating ED physician is familiar with. Full patient monitoring in line with the RCEM guidance on safe procedural sedation, including EtCO2 monitoring, must be used in all cases in which sedation is administered if possible. Early involvement of other specialties such as anaesthetics should be considered.

Seclusion Seclusion is defined (MHA) as involuntary confinement of a patient alone in a room or area from which patient is physically prevented from leaving. Its sole aim is to contain severely disturbed behaviour that is likely to cause harm to others. Controversial even in psychiatry!

Aftercare for a restrained patient do not forget about patient during a busy ED shift! repeat obs! fill any gaps in your history and physical examination think about side effects of any intervention plan for the timely removal of any physical restraints

Disposition planning - Medical admission clear alternative reason for agitation other than a psychiatric cause ( ex drug intoxication) doubt of a psychiatric cause of agitation hx of non-psychiatric etiology abnormal vital signs abnormal physical examination

Disposition planning - Psychiatric Consultation agitated behavior is a manifestation of active psychiatric disease patient is unable to care for him/herself is suicidal or homicidal ask for Police or security team

Pitfalls Failure to recognise underlying medical causes for the behaviour, e.g. Hypoxia or head injury. Be aware that acute changes in behavior are a medical condition until proven otherwise! Failure to disengage, when danger signs are present i.e. not recognizing the need for physical restraint in an appropriate and timely fashion. Dismissing challenging patients from the department, before excluding significant medical or psychiatric causes.

PS, 32ys – 28.08.18, hs 16.05 Verbal de-escalation Taking hx (?heroin use) Clinical exam (?PR exam) VBG – BM 6.6, pH 7.42, bicarb 25mmol Blood tests – normal AXR – no foreign body Urine toxicology – cannabis pos CT head - normal

PS, 32ys – 28.08.18, hs 16.05 Dgn – Acute Confusion ? Cause Referred to Medical Team Would you do anything different?

PS, 32ys – 28.08.18, hs 16.05 Admitted under Medical Team for 24 hours observations No other investigations repeated Dgn – Drug Induced Psychosis (Cannabis Use) Transferred to Psychiatric Team

Practical Message Obtain more historical information. If you feel endangered by the patient, leave immediately and make colleagues and staff aware of potential violence. Consider blood glucose. Look for signs of trauma, infection and intoxication. Address agitated behaviour and potential violence as soon as it is recognized. Any physical intervention must be reasonable, proportionate and necessary, as determined by the person at the time, in order to be lawful.

References RCEM - Guidelines for the Management of Excited Delirium / Acute Behavioural Disturbance (ABD) – May 2016 http://www.nice.org.uk/guidance/ng10 - May 2015

THANK YOU!