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

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

3. 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

4. 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.

5. 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

6. 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

7. “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.

8. “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).

9. 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

10. 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.

11. 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.

12. 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

13. 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).

14. 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.

15. 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

16. 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

17. 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

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

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

20. 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

21. 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.

22. 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

23. Physical Restraint

24. Physical Restraint

25. 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

26. 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 mg
PO/IM/IV
30-60 min
Extrapyramidal symptoms, Neuroleptic Malignant Syndrome

27. 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 hrs
15-45 min IM
3-6 hrs PO
Orthostatic hypotension

28. 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

29. 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.

30. 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.

31. 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!

32. 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

33. 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

34. 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

35. 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.

36. 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

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

38. PS, 32ys – , 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

39. 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.

40. References
RCEM - Guidelines for the Management of Excited Delirium / Acute Behavioural Disturbance (ABD) – May 2016
- May 2015

41. THANK YOU!