Agitated Patients: Clinical Overview and Problem Definition FERNE/MEMC Session: Agitated Patients: Clinical Overview and Problem Definition Leslie Zun, MD, MBA, FAAEM Professor and Chair Rosalind Franklin University/Chicago Medical School Department of Emergency Medicine Mount Sinai Hospital Les Zun, MD, MBA, FAAEM

Disclosures Alexza Pharmaceuticals Sanofi-Aventis FERNE/MEMC Session: Disclosures Alexza Pharmaceuticals Sanofi-Aventis Les Zun, MD, MBA, FAAEM

Agitation Definition Escalation Signs of agitation Excessive verbal and/or motor behavior Escalation Verbal Physical Violence Signs of agitation Pacing Irritable Affective liability Verbal outbursts Clenching fists or jaws Threatening or destructive behavior Slamming or banging objects Les Zun, MD, MBA, FAAEM

Prevalence Psychiatric patients in US Prevalence of agitation in US 4.3 million ED US visits per year 5.4% of ED patients Prevalence of agitation in US Up to 1.7 million ED visits Incidence of violence in US 50% of healthcare providers in their career 51% of MDs and 67% of nurses in ED were physically assaulted in the last 6 months 2/3 containment and 1/3 random Les Zun, MD, MBA, FAAEM

Etiology Drug and alcohol intoxication or withdrawal Medical Hypoglycemia Hyperthyroidism Delirium Dementia Head Trauma Temporal Lobe Epilepsy Psychiatric Schizophrenia Mania Agitated depression Personality disorder – Antisocial, borderline PT Akathisia Les Zun, MD, MBA, FAAEM

Etiology Drug and alcohol intoxication or withdrawal Medical Hypoglycemia Hyperthyroidism Delirium Dementia Head Trauma Temporal Lobe Epilepsy Psychiatric Schizophrenia Mania Agitated depression Personality disorder – Antisocial, borderline PTSD Akathisia Etiology Les Zun, MD, MBA, FAAEM

Evaluation Differentiate medical from psychiatric etiology Age Prior history Vital signs Physical examination findings Focal neurologic findings Glucose Oxygenation Laboratories? Radiography-CT Scan Delirium vs. dementia Les Zun, MD, MBA, FAAEM

Delirium vs. dementia Delirium Dementia Onset Acute Slow Awareness Reduced Clear Alertness Fluctuates Normal Orientation Impaired Memory Perception Hallucinations Intact Thinking Disorganized Vague Language Word finding difficulty Les Zun, MD, MBA, FAAEM

Patient Identification Citrone, L, Volavka: Violent patients in the emergency setting. Psych Clinic NA 1999;22:789-801. High risk Schizophrenia + substance abuse + medication non-compliance > Schizophrenia >Affective disorders Factors that precipitate violent behavior alone or in combination Comorbid substance abuse, dependence or intoxication Hallucinations or delusions Poor impulse control Character pathology Chaotic environment Les Zun, MD, MBA, FAAEM

Chaotic Environment Level of Agitation From ED Arrival Zun, LS and Downey, LA: Level of agitation of patients presenting to an emergency department. Primary Care Companion J Clin Psychiatry 2008;10:108-113. Les Zun, MD, MBA, FAAEM

Progression Do all patients progress? Which patients progress? How to prevent progression? Les Zun, MD, MBA, FAAEM

Reason to treat agitated patients Prevent violence Up to 75% ED staff victims of violence Better able to assess the patient Binder, Rl, McNeil, DE: Contemporary practices in managing acutely violent patients in 20 psychiatric emergency rooms. Psych Services 1999;50:1553- 1554. 17 of 20 medical directors stated that the patients are so agitated that it is difficult to get vital signs. 14 of 20 said the protocol was to physically restrain patients and medicate them prior to a medical work-up Begin therapeutic process Fishkind, AB: Agitation II: De-escalation of the aggressive patient and avoiding coercion. Emergency Psychiatry, 2008. Collaborative interactions Elicit information Patients say all they want Include patients in planning Empathize Les Zun, MD, MBA, FAAEM

Treatment Treat medical condition Reduce stimulation Verbal de-escalation - “Talk em down” Alternatives to restraints Restrain Physical Chemical Combination Seclusion Les Zun, MD, MBA, FAAEM

Prevent Violence Brasic, JR, Fogel, D:Clinical safety Prevent Violence Brasic, JR, Fogel, D:Clinical safety. Psych Clinic NA 1999;22:923-940. Identify violent patients Search patients for weapons Use a comprehensive, collaborative approach to the patient Strategies Administrative Behavioral Environmental Les Zun, MD, MBA, FAAEM

Prevent Violence-Strategies Brasic, JR, Fogel, D:Clinical safety Prevent Violence-Strategies Brasic, JR, Fogel, D:Clinical safety. Psych Clinic NA 1999;22:923-940. Administrative Gangs involvement Evacuation plan Staff training Behavioral Be direct, polite and respectful Keep close to open exit Listen to patient Use non-threatening speech and behavior Security alert Environmental Monitor rooms Well trained security presence – Clinical training programs eg CPI Panic alerts Les Zun, MD, MBA, FAAEM

Agitated Patients: Clinical Overview and Problem Definition Summary Agitation and violence common in ED Evaluate for possible treatable conditions Apply techniques to reduce agitation Identify agitated patients Be pre-emptive Utilize appropriate resources Employ strategies to prevent violence Search all patients Isolate and observe Les Zun, MD, MBA, FAAEM